This blog post is based on a recent webinar featuring Nicole Kupchik, MN, RN, CCNS, CCRN, PCCN-CMC, a Critical Care Clinical Nurse Specialist who is also a well-respected, nationally and internationally-recognized speaker on a variety of emergency and critical care topics.
In 2015, resuscitation guidelines were updated to reflect a change in the frequency and type of CPR training that hospitals should be requiring of providers. The update advised more frequent training to address the rapid deterioration in skills (deterioration begins as quickly as three months after training) and an approach that would include voice-assisted manikins (VAMs) to provide real-time feedback on compression rate, depth, hand placement, and ventilation frequency and volume.
What Should the Feedback Loop Look Like?
Nicole Kupchik is an advocate for CPR feedback, but she looks for ways to improve upon the guidelines’ recommendations. VAMs are extremely helpful in providing real-time corrective feedback to students who are learning or refreshing their skills, and the revised timeline for receiving the training makes it easier for providers to retain the skill, but are there additional ways to gather data on CPR performance and how should feedback be provided?
High-quality CPR is a significant determinant in the survival rates for in-hospital cardiac arrests, and Kupchik encourages providers to look at all potential sources of data on CPR performance in order to improve CPR skills.
The defibrillator is a likely (and readily available) source of great data that can support hospitals and providers on their quest to provide high-quality CPR. Most hospitals are using defibrillators whose pads are capturing real time data on things like compression rate, depth, and chest compression fraction. The defibrillator is able to wirelessly transmit a report to a database which can be downloaded and then reported to providers down to a minute-by-minute evaluation of the event.
Kupchik also recommends using this data to develop provider-specific report cards to help providers answer three basic post-event questions:
- What went well?
- What could have gone better?
- Were there any equipment or safety concerns?
The report cards can be powerful tools in analyzing and improving performance.
Evolving Recommendations on High Quality CPR Should Involve Training and Measurement
With in-hospital survival rates for cardiac arrest hovering at around 15%, it is important to identify key elements of high-quality CPR. While rate and depth of compressions have been a focus of researchers for years, chest compression fraction (the percentage of time spent delivering compressions) has become a focus within the last five years. Studies have found that the recommended percentage be at least 60%. High performing hospitals and EMS organizations are striving for 90% to provide optimal perfusion.
Should CPR Providers Model Their Teams After NASCAR?
VAMs and other devices that provide feedback can give us a more accurate sense of what that number is and can also help us understand what is happening when the number is lower than desirable. Pauses for handoffs, pulse checks, and defibrillation can result in lower compression fractions. Kupchik recommends a NASCAR style approach—training the team to perform like a pit crew.
She encourages hospitals to use a highly organized approach to CPR, similar to that of the NASCAR pit crew. How this team trains and performs may look different depending on the size and orientation of your hospital, but should always embrace a disciplined approach where each member has a specific role and a single person running the code. “To have high-quality CPR and high-performing teams, you cannot really expect a random group of people to show up and perform well,” says Kupchik. She also recommends mock codes to allow these teams to practice, measure, and refine their skills.
While measurement and feedback are key to building skills and confidence, Kupchik is quick to point out that this should not happen in an environment of blame. It can discourage participation in mock codes and even worse may discourage participation in an actual code. “This needs to be a really positive experience that people can learn from,” says Kupchik.
About Nicole Kupchik
Nicole Kupchik, MN, RN, CCNS, CCRN, PCCN-CMC, is a Critical Care Clinical Nurse Specialist who obtained her nursing degree from Purdue University in 1993 and a masters in nursing as a clinical nurse specialist from the University of Washington in 2008. In addition to her 20 years of nursing experience, Kupchik is a well-respected and nationally and internationally-recognized speaker on a variety of emergency and critical care topics. She has taught CCRN and PCCN certification review courses for more than 10 years. Kupchik has also authored articles on sepsis and hypothermia, has written five books, and is the host of a resuscitation-focused podcast.